The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Weigh the client and report any weight gain.

Reporting any client complaints of pain or discomfort.

Evaluate the client for sleep disturbances.

Note and report the client's food and liquid intake during meals and snacks.

Assess the client for weakness and fatigue.

Answer and Explanation

Correct Answer : A,B,D

A)   Correct- Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome.
B)   Correct- Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues.
C)   Incorrect- Evaluating the client for sleep disturbances involves assessing the client's sleep patterns, quality, and potential disruptions. This requires nursing judgment and a deeper understanding of the client's condition and potential contributing factors, so it's not appropriate to delegate this task to the UAP.
D)   Correct- Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.
E)   Incorrect- Assessing the client for weakness and fatigue involves a more comprehensive evaluation of the client's physical and physiological status, which requires nursing expertise. The nurse should directly assess and interpret these symptoms in the context of Cushing's syndrome to provide appropriate interventions.

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Correct Answer is ["A","B","D"]

Explanation

The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.

A. Clarify reality with the client about delusional thoughts. B. Reduce the client's interaction with others during day. C. Use distraction and therapeutic communication skills. D. Awaken the client for reality checks every 4 hours at night.

Correct Answer is C

Explanation

A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.

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The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is C

Explanation

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